Real world outcomes of lateral internal sphincterotomy vs botulinum toxin for the management of chronic anal fissures

Management of Hemorrhoids and Anal Fissures

Hemorrhoids and anal fissures are two of the most common benign anorectal diseases. Despite their high prevalence, diagnostic accuracy of benign anorectal disease is suboptimal at 70% for surgeons, especially for hemorrhoidal diseases. Once the diagnosis is correctly made, numerous medical and surgical treatment options are available, each with different rates of success and complications. In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures. The article discusses the pathophysiology, diagnosis, medical management, and procedures for hemorrhoids followed by a detailed overview on the management of anal fissures.

Botulinum toxin injection in outpatients for chronic anal fissure

OBJECTIVES

The aim of the study was to evaluate the effect of botulinum toxin (BT) injection on fissure healing in the treatment of chronic anal fissure (CAF) in outpatient conditions without any analgesia and sedation to the internal anal sphincter (IAS). The primary outcome measure was post-procedural pain. The secondary outcome measures were fissure healing and complications.

METHODS

Prospectively preserved data of 67 patients who received BT injections for CAF were analyzed prospectively. Demographic data, duration of symptomatic improvement, fissure location and number, parity, post-procedural pain, complications, continence status, response to treatment, and duration of follow-up were examined. Participants received bilateral (50 + 50 units) BT injections into the internal anal sphincter (IAS) in an outpatient setting.

RESULTS

Symptomatic improvement was observed in 58% of patients within 1 week. The complete response rate to treatment was 82% at a mean follow-up of 6 months. Patients with partial response to treatment (10%) were successfully treated with topical therapy, and patients with persisting fissures (8%) were successfully treated with partial lateral internal sphincterotomy (LIS). 14 patients (21%) reported some degree of transient incontinence at follow-up. Multiparous women experienced more symptoms of Incontinence (p = 0.00). Pre- and post-procedural Vas Score median values were 4. The 7th-week VAS score median value was 3.

CONCLUSION

Dysport injection under sedation-free outpatient conditions is an effective and safe alternative to LIS for the treatment of CAF, with tolerable procedural pain. All patients should be warned of transient incontinence.

'Bumps down under:' hemorrhoids, skin tags and all things perianal

PURPOSE OF REVIEW

There continues to be a concentrated effort to improve treatment options readily available for some of the most common perianal diseases: hemorrhoids, anal fissure and anal fistula. The emphasis remains on therapies that definitively address the underlying pathology yet minimize pain and risk of incontinence, have a short recovery period, and are cost-effective. In this analysis, recent developments in the literature are reviewed.

RECENT FINDINGS

Treatment of early stage hemorrhoidal disease remains the same. For grades II-IV disease, hemorrhoidal vessel ligation/obliteration with laser or bipolar energy are reported. For more advanced diseases, modifying the technique for hemorrhoidectomy to improve postoperative complications and pain is described. For anal fissure, a stepwise method continues to be the mainstay of treatment (initiating with vasodilators, followed by botox, and ultimately sphincterotomy), which decreases the risk of incontinence with proper patient selection and technique. Management of anal fistula continues to be challenging, balancing cure vs. risk of harm. Recent developments include modifications to ligation of intersphincteric fistula tract procedure and use of laser to obliterate the tract.

SUMMARY

Advancements in managing benign anorectal disease are ongoing. Several reports are novel, whereas others involve enhancing well-established treatment options by either operative technique or patient selection.

Incidence of anal incontinence among patients with anal fissure treated with Botox injection versus lateral sphincterotomy

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients with anal fissure, which technique has a lower of incidence anal incontinence: Botox injection or lateral sphincterotomy? The best evidence showed that Botox injection has lower incidence of incontinence.

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In patients with anal fissure.

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Which technique has a lower of incidence anal incontinence:

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Botox injection or lateral sphincterotomy?

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Botox injection has lower incidence of incontinence.